Copyright #ERS Journals Ltd 2002

Eur Respir J 2002; 19: 217224 European Respiratory Journal

DOI: 10.1183/09031936.02.00269802 ISSN 0903-1936
Printed in UK all rights reserved

A long-term evaluation of once-daily inhaled tiotropium in chronic

obstructive pulmonary disease

R. Casaburi*, D.A. Mahler#, P.W. Jones}, A. Wannerz, G. San Pedro, R.L. ZuWallack,
S.S. Menjoge**, C.W. Serby**, T. Witek Jr**

A long-term evaluation of once-daily inhaled tiotropium in chronic obstructive *Harbor-UCLA Research and Edu-
pulmonary disease. R. Casaburi, D.A. Mahler, P.W. Jones, A. Wanner, G. San cation Institute, Torrance, CA, #Dart-
Pedro, R.L. ZuWallack, S.S. Menjoge, C.W. Serby, T. Witek Jr. #ERS Journals Ltd mouth Hitchcock Medical Center,
2002. Lebanon, NH, zUniversity of Miami
School of Medicine, Miami, FL,
ABSTRACT: Currently available inhaled bronchodilators used as therapy for chronic
Louisiana State University Medical
obstructive pulmonary disease (COPD) necessitate multiple daily dosing. The present Center, Shreveport, LA, St Francis
study evaluates the long-term safety and efficacy of tiotropium, a new once-daily Hospital and Medical Center, Hart-
anticholinergic in COPD. ford, CT, and **Boehringer Ingelheim
Patients with stable COPD (age 65.28.7 yrs (meanSD), n=921) were enrolled Pharmaceuticals, Inc., Ridgefield, CT,
in two identical randomized double-blind placebo-controlled 1-yr studies. Patients USA. }St George9s Hospital, London,
inhaled tiotropium 18 mg or placebo (mean screening forced expiratory volume in UK.
one second (FEV1) 1.01 versus 0.99 L, 39.1 and 38.1% of the predicted value)
Correspondence: R. Casaburi, Harbor-
once daily as a dry powder. The primary spirometric outcome was trough FEV1 (i.e. UCLA Research and Education Insti-
FEV1 prior to dosing). Changes in dyspnoea were measured using the Transition tute, Building RB-2, 1124 W. Carson
Dyspnea Index, and health status with the disease-specific St. George9s Respiratory Street, Torrance, CA 90502, USA.
Questionnaire and the generic Short Form 36. Medication use and adverse events Fax: 1 310 3289849
were recorded. E-mail: casaburi@ucla.edu
Tiotropium provided significantly superior bronchodilation relative to placebo for
trough FEV1 response (y12% over baseline) (pv0.01) and mean response during the 3 h Keywords: Chronic obstructive
following dosing (y22% over baseline) (pv0.001) over the 12-month period. Tiotropium pulmonary disease
dyspnoea
recipients showed less dyspnoea (pv0.001), superior health status scores, and fewer exacerbations
COPD exacerbations and hospitalizations (pv0.05). Adverse events were comparable quality of life
with placebo, except for dry mouth incidence (tiotropium 16.0% versus placebo 2.7%, tiotropium
pv0.05).
Tiotropium is an effective, once-daily bronchodilator that reduces dyspnoea and Received: August 9 2001
chronic obstructive pulmonary disease exacerbation frequency and improves health Accepted after revision November 2
status. This suggests that tiotropium will make an important contribution to chronic 2001
obstructive pulmonary disease therapy.
Eur Respir J 2002; 19: 217224. This study was supported by Boehrin-
ger Ingelheim Pharmaceuticals, Inc.

Chronic obstructive pulmonary disease (COPD) is
characterized by reduced expiratory airflow and the
symptoms of cough, sputum production and dys-
pnoea [1]. The breathlessness associated with COPD
develops over many years, is a major reason for
seeking medical care and eventually limits daily
activities [2].
Bronchodilators are the mainstay of drug therapy
for COPD given their ability to improve airflow and
reduce breathlessness, the latter probably being
related to reduced hyperinflation [3]. Inhaled anti-
cholinergic drugs such as ipratropium have been used
since the 1970s in COPD and have emerged as a safe
and effective therapy [1, 4]. A limitation of these
agents is the need for frequent (i.e. four times daily)
dosing. Tiotropium, an agent in a new class of
anticholinergics, exhibits a longer duration of action
due to prolonged muscarinic receptor antagonism [5,
6]. These effects have the therapeutic advantage of
making once-daily dosing a possibility [7]. The present
article reports 1-yr data concerning the efficacy and
safety of tiotropium in COPD patients in terms of
bronchodilation, symptoms and other health out-
comes including adverse events. It characterizes
tiotropium as a new therapy for COPD.
Methods
Study design and conduct
Two identical clinical trials were designed to
establish the efficacy and safety of tiotropium
(Spiriva1; Boehringer Ingelheim, Ingelheim am
Rhein, Germany), including health outcomes. These
two trials have been combined in the present report to
provide a comprehensive efficacy and safety profile.
Fifty clinical centres participated in the double-blind
218 R. CASABURI ET AL.
placebo-controlled trials. These trials were approved
by each centre9s Institutional Review Board. All
patients provided written informed consent.
The study groups consisted of outpatients of either
sex who were 40-yrs-old and had a clinical diagnosis
of COPD, as defined by the American Thoracic
Society (ATS) [8]. Participants were required to have
at least a 10 pack-yr smoking history, clinically stable
airway obstruction, and a forced expiratory volume in
one second (FEV1) of 65% of predicted normal
values and 70% of forced vital capacity (FVC).
Patients were excluded if they had a history of asthma,
allergic rhinitis or atopy or a total blood eosinophil
count of 600 cells?mm-3. Bronchodilator responsive-
ness was not an entry criterion. Patients were also
excluded if they required regular daytime supple-
mental oxygen or were on doses exceeding the equi-
valent of 10 mg prednisone daily during the month
prior to entering the study. In addition, patients were
excluded if they had a recent history of myocardial
infarction (1 yr), heart failure (3 yrs) or cardiac
arrhythmia requiring drug therapy.
Treatments
Following a 2-week baseline period, patients were
randomly assigned within each study centre to receive
either tiotropium (18 mg) or placebo. Patients were
randomized in a 3:2 tiotropium:placebo ratio in order
to expose a greater number of patients to tiotro-
pium for safety evaluation. Subjects took, by inhala-
tion, active medication (tiotropium in lactose) or
placebo (lactose) once each morning from identically
appearing capsules via a dry powder inhaler device
(HandiHaler1; Boehringer Ingelheim, Ingelheim am
Rhein, Germany) [9]. Patients were permitted an
albuterol metered-dose inhaler, as needed, stable
doses of theophylline (i.e. unchanging doses that
had been used for 6 weeks prior to entry),
inhaled glucocorticosteroids and the equivalent of
10 mg?day-1 oral prednisone throughout the study
period. Finally, to treat acute COPD exacerba-
tions during the trial, investigators were permitted
to administer any additional medication deemed
necessary (excluding anticholinergic or long-acting
b-agonists). After 13 weeks, the investigators were
permitted to prescribe glucocorticosteroids or theo-
phylline preparations as necessary.
Spirometric testing
Spirometric testing was conducted on treatment day
1 and after 1, 7, 13, 25, 37 and 49 weeks of therapy.
Drug was administered at the same time each day
(between 07:00 and 09:00 h). On test days, FEV1 and
FVC were recorded 1 h prior to dosing, just prior
to dosing, and 30, 60, 120 and 180 min after study
drug administration. Spirometric manoeuvres were
conducted in triplicate and the greatest FEV1 and
FVC used in subsequent analyses. Predicted normal
values for FEV1 and FVC were derived from standard
equations [10]. Spirometers were required to meet
ATS standards [11].
In order to ensure standardized conditions on
spirometric test days, subjects discontinued theophyl-
line 24 h prior to spirometric testing (compliance
was assessed by measuring theophylline levels prior
to testing and noting patients with levels of
5.0 mg?mL-1; this threshold was exceeded in only
12% of measurements). Albuterol and inhaled
corticosteroids were stopped 12 h prior to spiro-
metric testing.
Other observations
Before entry and upon trial completion, patients
underwent medical history checks, physical exami-
nation, and routine blood chemistry and haematology
testing as well as 12-lead electrocardiography to
exclude other important diseases and to monitor
study medication safety. Each subject also performed
peak expiratory flow rate (PEFR) measurements in
their home twice daily (upon arising and at bedtime)
using the AirWatchTM Monitor (Enact Health
Management Systems, Mountain View, CA, USA).
Study clinic visits were scheduled on the first day of
study drug administration, at the end of the first
week of therapy, every 3 weeks thereafter through-
out the first 13 weeks of treatment and every 6 weeks
for the next 36 weeks, in order to assess adverse
events, concomitant medication use and clinical sta-
tus. An exacerbation, detected through monitoring of
adverse events, was defined as a complex of respira-
tory events (i.e. cough, wheezing, dyspnoea or sputum
production) lasting w3 days. These were generally
treated with antibiotics and/or oral steroids.
Diary and interview assessments
Dyspnoea at baseline was assessed using the Base-
line Dyspnea Index (BDI) [12]. This instrument has
three domains (functional impairment, magnitude of
task and magnitude of effort), the sum of the values
giving a combined focal score. Changes in impairment
from baseline were measured using the Transition
Dyspnea Index (TDI) [12] on days 50 and 90 and
every 3 months thereafter. Generic and disease-
specific health status was evaluated by patients using
Short Form 36 (SF-36) [13] and St George9s
Respiratory Questionnaire (SGRQ) [14]. At each
visit during the treatment period, the investigator
recorded COPD symptom scores after reviewing the
patient9s daily diary (for wheezing, shortness of
breath, coughing and chest tightness) and recorded
a global evaluation of the patient9s overall condition
(1: poor; 8: excellent).
Statistical analysis
The statistical model was an analysis of covariance
with terms for treatment, clinic and baseline as
covariates. Discontinuation rates and proportions of
patients showing clinically meaningful responses were
compared across treatment groups using Fisher9s
 EVALUATION OF TIOTROPIUM IN COPD 219

exact test. Proportions of patients experiencing at Table 1. Demographics and baseline characteristics of
least one COPD exacerbation and hospitalization the randomized patients
associated with such exacerbations were compared Tiotropium Placebo
across treatment groups using logistic regression
analysis. Only those COPD exacerbations recorded
as adverse events were used for comparison in order Patients n 550 371
Sex male/female 366/184 233/138
to eliminate day-to-day fluctuations in symptoms. Age yrs 659 659
The intention-to-treat principle of including all ran- Height cm 171.19.6 170.59.5
domized patients was used in all efficacy analyses. Weight kg 76.917.7 75.517.5
Patients who had missing baseline data, or v2 weeks Smoking history 6331 5930
of data for certain end points, were excluded from pack-yrs
the 1-yr comparisons for those end points. Patients Duration of 8.67.4 8.16.8
who were unable to complete all of their visits due disease yrs
to drug expiration discontinued their study drug at the FEV1 L 1.040.41 1.000.44
9-month visit but were considered complete patients. FEV1 % pred 39.113.7 38.114.1
When patients discontinued due to worsening of FVC L 2.310.79 2.230.78
FEV1/FVC % 45.811.6 45.511.6
disease (5% of patients), missing data were imputed Prestudy medication for
using the least favourable data observed prior to COPD n (%)
discontinuation. In all other cases, missing data Anticholinergics 302 (55) 217 (59)
following patient withdrawal were imputed by carry- b2-agonist, inhaled 546 (99) 368 (99)
ing the last observation forward. In order to assess the Inhaled steroids 239 (44) 149 (40)
impact of imputation, data were also analysed based Oral steroids 31 (6) 33 (9)
on patients who completed the study to 12 months Theophylline 123 (22) 94 (25)
alone. This sensitivity analysis showed that the results Data are presented as meanSD unless otherwise indicated.
were consistent with those obtained after imputation No significant differences were seen between the two groups.
of missing data. FEV1: forced expiratory volume in one second; FVC: forced
vital capacity; COPD: chronic obstructive pulmonary
disease; % pred: percentage of the predicted value.
Sample size
(pv0.01) (fig. 1). With chronic therapy, predose
A sample size of 60 patients per group was FEV1 (i.e. trough) was elevated 1101013010 mL
calculated as adequate to detect a difference of (111131%) over baseline (meanSEM); this was
0.13 L in trough FEV1 based on an SD of 0.215 L. superior to placebo by 1201015020 mL (pv0.01)
To ensure adequate safety exposure, a sample size on the various assessment days. Significant differ-
of 240 patients was selected for each trial. ences from placebo were also observed for peak
response and mean (i.e. over the 3 h following dosing)
response. The mean FEV1 increase over baseline
Results during the 3 h following dosing for tiotropium ranged
1901022010 mL (191221%); this was superior
Of 921 patients enrolled (n=550 for tiotropium; to placebo by 1401022020 mL. Figure 1 reveals
n=371 for placebo), a higher percentage completed the
study in the tiotropium group (81.3%) than in the
placebo group (72.2%) (pv0.05). A lower percentage 1.3
failed to complete due to adverse events (9.6%) and
lack of efficacy (2.4%) in the tiotropium group than


in the placebo group (13.7 and 7.0%, respectively) 1.2







(pv0.05 for both). In addition, 24% of patients
discontinued the trial prior to the end of the study
FEV1 L

due to drug expiration. Although further supply of the
study drug was originally planned, it was deemed
unnecessary as the target sample size was attained due
to the lower-than-expected frequency of early with-
drawals.
The study population characteristics are listed in
table 1. Patients were generally in their seventh decade
of life, had a mean cigarette exposure of 61 pack-yrs
and a mean FEV1 of 1.02 L, and were predominantly
male. Groups were balanced for all characteristics.
Spirometry
Tiotropium produced acute bronchodilation upon
initial dosing superior to that produced by placebo
1.1
1.0
0.9
-1 0 1 2 3
Time after administration h
Fig. 1. Mean response to tiotropium (+) or placebo (%) on
days 1 (), 8 (.......), 92 (- - - -), 176 ( ) and 344 ( -- --)
of the 1-yr trial. Note that the elevation over baseline prior to
drug administration on days subsequent to the first treatment day
in the tiotropium group is evidence of tiotropium9s 24-h duration
of action. The SEM for the mean differences between groups
ranged 0.010.02 L. FEV1: forced expiratory volume in one second.
220
consistent bronchodilation (i.e. no tachyphylaxis)
throughout the study. The FVC responses paralleled
those of FEV1. Mean increase in trough FVC ranged
2602029020 mL (121131%) over baseline and
ranged 4202051020 mL (191231%) over base-
line during the 3 h following treatment.
Peak expiratory flow rate
PEFR was higher in the tiotropium group relative
to placebo for both morning and evening measure-
ments (pv0.05). Differences in weekly means for
morning PEFR ranged 114256 L?min-1 over the
1-yr period (fig. 2).
Symptoms
BDI scores indicated moderate impairment in each
of the three domains at baseline. Significant improve-
ments in breathlessness compared to baseline, as
assessed using the TDI focal score, were achieved by
the first assessment (day 50) and maintained for the
entire year in the tiotropium group compared to
placebo. Differences ranged 0.80.21.10.2 (pv0.001
a) 240
Mean weekly PEFR Lmin-1
230
220
210
200
190
b) 240
Mean weekly PEFR Lmin-1
230
220
210
200
190
0 4 8 12 16 20 24 28 32 36 40 44 48 52
Time weeks
Fig. 2. Mean peak expiratory flow rate (PEFR) measurements
over the course of the 1-yr study for: a) morning; and b) evening
assessments (: tiotropium (n=507); .......: placebo (n=332)). The
data represent weekly means. Differences between treatments were
significant at all weeks (pv0.05). Means were adjusted for
treatment, centre and baseline. The SEM for the mean difference
between treatment groups ranged 36 L?min-1.
R. CASABURI ET AL.
1.6
1.4 ***
***
1.2 ***
*** ***
1.0
TDI focal score
0.8
0.6
0.4
0.2
0.0
-0.2
-0.4
0 40 80 120 160 200 240 280 320 360
Test day
Fig. 3. Mean Transition Dyspnea Index (TDI) focal score at the
five assessment points over the course of the 1-yr trial (+:
tiotropium (n=507); %: placebo (n=325)). Data are presented as
meanSEM. Means were adjusted for treatment, centre and
Baseline Dyspnea Index. A higher score denotes less dyspnoea.
***
: pv0.001.
at all time points) (fig. 3). The proportion of patients
who achieved a score of 1.0 (corresponding to a
clinically important difference) in TDI focal score was
significantly greater in the tiotropium group at all five
assessment points (4247%) than in the placebo group
(2934%) (pv0.01).
COPD symptom scores showed statistically signi-
ficant improvements for shortness of breath and
wheezing (pv0.05), but not for cough and chest
tightness, compared with placebo.
Health outcomes
Exacerbations. The proportion of patients experi-
encing at least one COPD exacerbation was lower
in the tiotropium group (36%) than in the placebo
group (42%) (14% reduction, pv0.05). There was a
significant increase in the time to first exacerbation in
the tiotropium group relative to placebo (p=0.011).
There were significantly fewer exacerbations in the
tiotropium group (0.76 events?patient-yr-1) compared
to those in the placebo group (0.95 events?patient-yr-1),
a 20% reduction (p=0.045). In addition, there
were significantly fewer hospitalizations associated
with exacerbations in the tiotropium group
(0.086 events?patient-yr-1) compared to the placebo
group (0.161 events?patient-yr-1), a 47% reduction
(p=0.019). The proportion of patients hospitalized
for exacerbation was lower in the tiotropium group
(5.5%) than in the placebo group (9.4%, 41%
reduction, pv0.05). Patients on tiotropium spent
significantly fewer days in hospital for exacerba-
tions (0.6 days?patient-yr-1) compared with placebo
(1.2 days?patient-yr-1, 50% reduction, p=0.023).
Chronic obstructive pulmonary disease-specific health
status. Treatment-related changes in evaluation
scores for health status, as assessed by the disease-
specific SGRQ, are shown in figure 4. Tiotropium
demonstrated improvements in each domain as well
 EVALUATION OF TIOTROPIUM IN COPD
a) 0
-1
SGRQ score
-2
* Adverse events considered
-3
* *
-4 * * * Deaths n (%)
* Serious adverse events n (%)
* Adverse events leading
-5 *
*
-6
b) 2
1 The number of albuterol doses taken during the
0
SGRQ score
-1
-2
-3
-4
-5
6 9
Time months
Fig. 4. The mean total (q) and subscale (symptoms (%), activity
(F) and impact (E)) scores, in comparison to baseline, for the St
George9s Respiratory Questionnaire (SGRQ) at three assessment
points in the 1-yr study for: a) tiotropium; and b) placebo. A
lower score indicates an improvement in health status (.......:
clinically meaningful response (4-unit improvement)). D: change
in. *: pv0.05 versus placebo.
as in total score, with significant improvements
observed relative to placebo (pv0.05). In addition
to a statistically significant improvement in mean
response, a significantly greater percentage of patients
in the tiotropium group (49%) showed at least a four-
unit improvement in total score, recognized as a
clinically meaningful response, compared to those in
the placebo group (30%).
Generic health status. As documented by the SF-36,
patients taking tiotropium demonstrated improvement
in physical health domains relative to placebo (physical
function, role physical and general health, as well as
summary score) on all assessment days (pv0.05). The
mean improvements with tiotropium were 4.6 for
physical function, 9.0 for role physical, 4.0 for general
physical health and 2.4 for the physical summary score
compared to placebo at the end of trial participation.
There was no significant difference between treatment
groups in the mental health summary, although
significantly greater (pv0.05) scores were observed
for tiotropium in the domains of vitality and social
function on four of five test days. The mean
improvement with tiotropium was 3.2 for vitality
and 3.9 for social function compared to placebo at
the end of trial participation.
221
Table 2. Adverse event profile
Tiotropium Placebo
Subjects n 550 371
Adverse events n (%) 495 (90.0) 338 (91.1)
104 (18.9) 34 (9.2)*
* drug related n (%)
* Dry mouth n (%) 88 (16.0) 10 (2.7)*
7 (1.3) 7 (1.9)
99 (18.0) 78 (21.0)
to discontinuation n (%) 53 (9.6) 51 (13.7)
*: pv0.05.
Medication use. Patients recorded their "as needed"
doses of albuterol (1 dose is equivalent to 12 puffs).
baseline period was comparable for the two treat-
ment groups (tiotropium 3.70.12 versus placebo
3.40.14 doses?day-1). During the last week of
participation in the trial, mean albuterol use was
3.20.11 and 4.10.13 doses?day-1 in the tiotropium
and placebo groups, respectively (pv0.01).
Physician9s global assessment. Patients in the tiotro-
pium group showed greater improvement in
physician9s global evaluation than those in the
12 placebo group on all test days (pv0.01). Physician9s
global evaluation scores ranged 4.945.05 for the
tiotropium group compared to 4.594.74 for the
placebo group over 11 visits throughout the year.
Adverse effects
The proportion of patients experiencing an adverse
event over the course of the 1-yr study was similar in
the tiotropium and placebo groups (table 2). The only
adverse event which differed significantly between the
groups was dry mouth, which occurred in 16% of
tiotropium patients and 2.7% of placebo patients. Dry
mouth was mild in the majority, and v1% withdrew
for this event. There were no significant differences in
the proportion of patients with serious adverse events,
in those withdrawing for adverse events or in deaths
during the study (table 2).
Discussion
Bronchodilators are currently the mainstay of
drug therapy for COPD [3]. The concept that airflow
limitation in COPD is mainly irreversible is incorrect,
as numerous studies have shown appreciable improve-
ment in lung function with bronchodilator therapy in
COPD patients not specifically selected based on
standard reversibility criteria [15, 16]. COPD appears
to be more effectively treated by anticholinergic drugs
than by sympathomimetics [3], probably due, in
part, to the role of the cholinergic nervous system in
controlling airway tone in these patients [4]. In current
treatment guidelines, anticholinergics are recom-
mended for maintenance therapy in COPD [1, 2, 8, 17].
222 R. CASABURI ET AL.
The recent clinical development of tiotropium
represents an advance in bronchodilator therapy
in that its pharmacological features translate into
clinically important attributes. Tiotropium binds
significantly longer (hours) to the M3 muscarinic
receptor (responsible for bronchodilation) than does
ipratropium (minutes). This observation finds its
clinical correlate in sustained improvements in air-
flow. Tiotropium also dissociates more rapidly from
the M2 receptor (whose stimulation reduces acetylcho-
line release) than from the M3 receptor, antagonism of
which promotes bronchodilation. Although func-
tional correlates of these features have been demon-
strated in experimental test systems of acetylcholine
release and smooth muscle relaxation [18], the clinical
effects of "kinetic receptor subtype selectivity" [19]
have not been directly studied.
Single- [20] and multiple-dose [5] studies of tiotro-
pium in COPD have demonstrated its prolonged
duration of action. In a multiple-dose study of tio-
tropium, doses ranging 4.536 mg showed little dose
dependency in spirometric outcomes, and the optimal
therapeutic dose was judged to be 18 mg [5]. The 24-h
effectiveness of this dose was confirmed in a trial in
which serial spirometry over the entire dosing interval
demonstrated significant bronchodilation [21]. The
first 13 weeks9 spirometric results from one of the
trials reported here have recently been published [22],
and those findings were confirmed during the 1-yr
study period. The elevation of trough FEV1 over
baseline (fig. 1) demonstrates the appropriateness of
once-daily administration. The persistence of FEV1
response over a full year of therapy indicates that
tachyphylaxis does not occur during this time period.
Higher evening PEFR responses in the tiotropium
group (fig. 2b) are notable in light of their lesser use
of rescue albuterol. The daily patient recordings of
morning PEFR prior to dosing (fig. 2a) reinforce the
concept that tiotropium9s action persists for 24 h.
Although spirometric assessment is important for
the characterization of airflow impairment and
improvements following therapy, other consequences
of chronic disease relate to a patient9s disability and
handicap. Patients assigned to tiotropium experienced
a significant improvement in dyspnoea relative to the
placebo group, as assessed by the TDI. In addition, a
significantly greater proportion of patients manifested
an increase of 1 unit on the TDI, a change that
inherently reflects a clinically meaningful improve-
ment based on the instrument9s scoring description
[12]; this is supported by analyses against general
outcome measures [23]. The reduction in breath-
lessness with tiotropium is further supported by the
significant reduction in the use of rescue albuterol as
well as significant improvements in physician9s global
evaluation and the symptom diary rating of dyspnoea.
Alteration in COPD exacerbation frequency may be
one of the most important health outcomes, as it
significantly impacts upon the patient9s quality of life
[24] and is a major contributor to healthcare utili-
zation [25]. In the present studies, tiotropium was
associated with both fewer exacerbations and hospi-
talizations as well as prolonging the time to the first
exacerbation. Treatment with inhaled corticosteroids
has also been shown in some studies to reduce
exacerbation rate [26, 27] and severity [28], suggesting
a role for airway inflammation in disease exacerba-
tion. In another report, salmeterol was associated
with a prolonged time to exacerbation, but this study
was limited to 3 months [29]. In another 12-week
study, exacerbations were significantly reduced in
patients treated with ipratropium plus salmeterol,
but not salmeterol alone [30]. The mechanism(s)
by which tiotropium reduces COPD exacerbations
is not yet clear. Health status was improved with
tiotropium relative to placebo, confirming the overall
benefit of therapy to the patient. Improvements that
were at or around the level of clinical significance
(a decrease of 4 units) [14] were observed in all SGRQ
domains compared with placebo. Further, a signi-
ficantly higher proportion of patients exceeded a
4-unit improvement in the group receiving tiotropium.
The largest difference between groups was observed
in the impact domain of the SGRQ. This component
reflects disturbances to everyday life imposed by the
disease, including aspects of psychological distress
as well as limitations put upon daily activities and
social function. Although an unproved hypothesis, the
reductions in dyspnoea and exacerbation frequency
may account for the improvements seen in health
status.
It is interesting to contrast these SGRQ score
changes with those recently reported in COPD
patients taking the inhaled glucocorticosteroid fluti-
casone (Inhaled Steroids in Obstructive Lung Disease
(ISOLDE) trial, [26, 27]). That study assessed health
status every 6 months over a 3-yr period. Health
status was shown to decline (rising SGRQ scores) in
the group receiving placebo. Fluticasone reduced the
rate of deterioration compared with placebo-treated
patients, but at no time (including the first year) did
fluticasone induce a significant improvement in health
status. In contrast, although the overall observation
period was shorter, the present study demonstrated
that tiotropium produced an improvement in health
status that was sustained over a 1-yr period. Few data
are available with other interventions, particularly
beyond 3 months of observation. Over 16 weeks, the
b-agonist salmeterol has been reported to improve
health status as measured by the SGRQ at 50 mg; it
did not do so, however, at 100 mg (both twice daily)
[31]. Longer-term data are not available.
The present trial results indicate that tiotropium is
an effective once-daily bronchodilator. Tiotropium
was associated with consistent physiological and
health outcome benefits including reduced dyspnoea,
fewer exacerbations and improved health status; these
benefits were sustained over a 1-yr period. Compa-
rator 1-yr clinical trials versus ipratropium have been
performed and indicate consistency of the improve-
ments with tiotropium across multiple clinical out-
comes [32]. Its attributes, defined in these long-term
clinical trials, together with its demonstrated safety
suggest that tiotropium is likely to provide an
important contribution to the therapy of patients
with symptomatic chronic obstructive pulmonary
disease.
 EVALUATION OF TIOTROPIUM IN COPD
Acknowledgements. The authors are grateful
to the patients and their families, and the
coordinators, nurses and therapists for their
dedication to the study.
Participants: D. Amin, A. Anzueto, D.
Auerbach, R. Baughman, H. Blumberg, S.A.
Brazinski, R.D. Briggs, J.M. Cary, R. Casaburi,
J.R. Castle, H. Chandarana, T. Craig, A.C.
DeGraff, E. Diamond, J. Donohue, D.J. Elias,
J. Flanders*, M. Friedman, M.D. Goldman,
N.J. Gross, K. Gunther*, W.W. Henderson IV,
F.C. Hiller, M. Janes, T.P. Kaine, J. Karpel,
S. Kesten*, S. Knoper, P. Koch*, A. Kotch,
T.S. Lemire, D. Levin, B. Levine, J. Liu,
D. Mahler, M. Mandel, K.S. Miller, P. Montner,
C.A. Piquette, R. Player, N. Pushlar*, J.W.
Ramsdell, K. Reilly*, L. Repsher, D.A. Ruff,
G. San Pedro, J.P. Schilling, J. Skatrud,
D.D. Smith, J.A. Tita, J.D. Truwit, A. Wanner,
J.G. Weg, I.M. Weisman, L.A. Weiss, R.L.
ZuWallack (*Boehringer Ingelheim).
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